Updated: 2/24/2020

Orthopedic Trauma

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Snapshot
  • A healthy 25-year-old man is brought to the ED after falling out of a second-floor window. He is supported by two friends. All appear to be inebriated with injected conjunctiva. The patient complains that his right thigh is in pain. He reports having landed on his feet. Primary survey is unremarkable. Blood pressure is 100/60 mmHg, pulse is 80/min, respirations are 18/min, and SaO2 is 99% on RA. On physical exam, he cannot passively or actively move his right leg without wincing in pain. AP and lateral radiographs of his right femur reveal an isolated oblique diaphyseal fracture. Radiographs of his other femur, knees, hip, and lumbar spine are unremarkable. Urine drug screen is positive for marijuana. Pain medications are provided and closed reduction with a splint is applied. The patient is admitted to the orthopedics service.
Introduction
  • Orthopedic trauma can be part of any high-energy mechanism (MVC, fall)
    • spinal and/or visceral injuries may coexist
    • in ED setting, goal is to quickly diagnose or rule out life or limb threatening injuries
      • non-threatening fractures can be reduced and immobilized
      • pain relief and proper follow-up are crucial for appropriate discharge
Life and Limb-Threatening Orthopedic Injuries
  • All of the following are appropriate reasons for emergent surgical consultation
  • Life-threatening
    • pelvic fracture
    • massive long bone injuries (high risk of fat emboli)
    • vascular injury proximal to knee and/or elbow
    • traumatic amputations
  • Limb-threatening
    • compartment syndrome
    • open fractures
    • knee/hip dislocation
    • fracture proximal to knee and/or elbow
    • crush injuries
    • fracture/dislocation of ankle
 Classification of Fractures
  • Fractures are described by integrity of skin, location, fracture pattern, and displacement
    • integrity of skin/soft tissue
      • closed or open (blood or fat droplets at puncture site)
    • location
      • epiphyseal, metaphyseal, diaphyseal
    • orientation/fracture pattern (see image below)
      • transverse
        • perpendicular to long axis of bone
        • suggests direct, high-energy trauma
      • oblique
        • angular
        • suggests rotational trauma
      • spiral
        • complex, multiplanar fracture line
        • suggests rotational, low-energy trauma
      • comminuated
        • more than 2 fracture fragments
      • avulsion
        • fragment off of bone due to tendon / ligament tear or pull
        • suggests high-energy trauma, often in children
      • impacted
        • impaction of bone
        • commonly in midline or truncal skeleton
      • fissure
        • parallel to long axis of bone
      • greenstick 
        • incomplete fracture of cortex
      • torus 
        • compressive force to more flexible bone
        • bulging of the periosteum/cortex on radiography
    • displacement
      • refers to distal fragment in or not in anatomic alignment with proximal fragment
      • varus: apex away from midline
      • valgus: apex toward midline

 Evaluation
  • Primary and secondary survey with resuscitation
    • SEADS inspection: Swelling, Erythema, Atrophy, Deformity, Skin changes
    • increased pain with passive stretch, or pain out of proportion to injury suggests compartment syndrome
    • palpate all bones/joints and actively move joints that affected and those above/below
    • assess vascular and neurological statuses distal to injury
  • Imaging
    • radiographs
      • lateral cervical spine, AP chest, pelvis
      • AP and lateral of all injured bones
Management
  • For all life and limb-threatening injuries, surgical consult (general, vascular, orthopedics)
  • Fracture management includes reduction to maintain bone alignment and integrity
    • reduction can be closed or open
      • closed reduction
        • traction applied in long axis of limb to reverse mechanism that produced fracture
          • this fatigues the contracted muscles so that proper alignment can be achieved
        • intravenous sedation and muscle relaxation used
      • open reduction
        • used if closed reduction fails, cast or traction cannot be applied due to site (e.g., hip)
        • used if fracture is pathologic (endocrinological, oncological)
        • used in open fractures
    • reduction is maintained via external or internal stabilization
      • external stabilization
        • splints, casts, traction, external fixator
      • internal stabilization
        • percutaneous pinning, fixation with screws/plates/wires/rods
    • physical rehabilitation and therapy are needed to regain function and avoid joint stiffness
  • Goal of open fracture management is to minimize risk of osteomyelitis
    • gross debris removal, irrigation with normal saline, and sterile dressing
    • tetanus prophylaxis with toxoid or immunoglobulin as needed
    • intravenous antibiotics for at least 3 days
      • first-generation cephalosporins for gram-positives
        • vancomycin if MRSA positive
      • aminoglycosides for gram-negatives
      • penicillin added if soil-contaminated for Clostridium perfringens
    • reduce and splint fracture
    • NPO for definitive surgical irrigation and debridement in 6-8 hours

References

 

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